Renal auto-transplantation promotes cortical microvascular network remodeling in a preclinical porcine model.

The vascular network is a major target of ischemia-reperfusion, but has been poorly investigated in renal transplantation. The aim of this study was to characterize the remodeling of the renal vascular network that follows ischemia-reperfusion along with the most highly affected cortex section in a preclinical renal transplantation model. There were two experimental groups. The first was a grafted kidney group consisting of large white pigs for which the left kidney was harvested, cold flushed, preserved for 24 h in the University of Wisconsin's preservation solution, and then auto-transplanted (n = 5); the right kidney was removed to mimic the situation of human kidney transplantation. The second group (uni-nephrectomized kidney group) consisted of animals that underwent only right nephrectomy, but not left renal transplantation (n = 5). Three months after autotransplantation, the kidneys were studied by X-ray microcomputed tomography. Vessel morphology and density and tortuosity of the network were analyzed using a 3D image analysis method. Cortical blood flow was determined by laser doppler analysis and renal function and tissue injury assessed by plasma creatinine levels and histological analysis. Renal ischemia-reperfusion led to decreased vascular segment volume associated with fewer vessels of less than 30 µm, particularly in the inner cortex:0.79 ± 0.54% in grafted kidneys vs. 7.06 ± 1.44% in uni-nephrectomized kidneys, p < 0.05. Vessels showed higher connectivity throughout the cortex (the arborescence factor of the whole cortex was less in grafted than uni-nephrectomized kidneys 0.90 ± 0.04 vs. 1.07 ± 0.05, p < 0.05, with an increase in the number of bifurcations). Furthermore, cortical blood flow decreased early in kidney grafts and remained low three months after auto-transplantation. The decrease in microvasculature correlated with a deterioration of renal function, proteinuria, and tubular dysfunction, and was associated with the development of fibrous tissue. This work provides new evidence concerning the impact of ischemia-reperfusion injuries on the spectrum of renal vascular diseases and could potentially guide future therapy to preserve microvessels in transplantation ischemia-reperfusion injury.

Testing of a Complete Training Model for Chest Tube Insertion in Traumatic Pneumothorax.

INTRODUCTION: Chest tube insertion is a frequent procedure in cases of traumatic pneumothorax, but severe complications can occur if not well performed. Although simulation-based training in chest tube insertion has improved performance, an affordable and realistic model for surgical insertion of a chest tube is lacking. OBJECTIVE: The objective was to design a model for surgical chest tube insertion that would be realistic, affordable, and transportable and that would reflect all extrathoracic and intrathoracic steps of the procedure. METHODS: The model was a task trainer designed by 4 experts in our simulation laboratory combining plastic, electronic, and biologic material. The cost of supplies needed for construction was evaluated. The model was used and tested over 30 months on 56 participants, of whom 44 were surveyed regarding the realism of the model. RESULTS: The model involved a half chest wall (lamb) on a plastic box, connected to a webcam facilitating assessment of the extrathoracic and intrathoracic steps of the procedure, for a cost of €60. Chest tubes, water seal package, and sterile instruments costed €200. All anatomic structures were represented during surgical insertion of chest tube. The demonstration contributed to teaching small groups of up to 8 participants and was reproducible over 30 months of diversely located courses. Anatomic correlation, realism, and learning experience were highly rated by users. CONCLUSIONS: This model for surgical chest tube insertion in traumatic pneumothorax was found to be realistic, affordable, and transportable. Furthermore, it allowed comprehensive assessment of the extrathoracic and intrathoracic procedural steps.

Reliability and validity of a new measurement of lumbar foraminal volume using a computed tomography.

PURPOSE: Measuring foraminal stenosis is generally determined by an area calculation. It is difficult to know exactly where it is most appropriate to measure. No precise data are available on a method for calculating the foraminal volume using a CT. To develop a new method for measuring lumbar foraminal volume, we analyzed repeatability and reliability for measuring methods for foraminal volume using CT. METHODS: The measurements were performed using a CT scan from ten healthy patients, with a mean age of 26.3 years. L3-L4, L4-L5 and L5-S1 foramen were studied, to obtain 60 foraminal measurements. Inter- and intra-observer reproducibility was calculated. Each series was analyzed using the VitreaCore® reconstruction software for volume calculation. RESULTS: Average volume measurements of 60 foramina and 20 L4-L5 foramina were, respectively, 1.17 and 1.25 mm(3) for observer 1 and 1.21 and 1.29 for observer 2. The intra-observer correlation coefficients for observer 1 when measuring all foramina and L4-L5 foramina were 0.98 and 0.99, respectively. For observer 2, coefficients were 0.90 and 0.92, respectively. The inter-observer correlation coefficients for observer 1 when measuring all foramina and L4-L5 foramina were 0.78 and 0.83, respectively. For observer 2, coefficients were 0.77 and 0.8, respectively. The average differences in intra- and inter-observer measurements regardless of the evaluator group were less than 0.2 mm(3). CONCLUSIONS: This is the first study measuring lumbar foraminal volume using CT. The excellent reproducibility of this simple measure can supplement a range of foramen measurement tools.

Compression stockings in ankle sprain: a multicenter randomized study.

OBJECTIVES: Ankle sprain is a frequently encountered traumatic injury in emergency departments and is associated with important health expenses. However, the appropriate care of this traumatic injury remains a matter of debate. We tested the hypothesis that compression stockings speed up recovery from ankle sprain. METHODS: Recent (<48 hours) cases of ankle sprain without other traumatic injury in patients aged between 18 and 55 years were included. Patients were randomly allocated to placebo Jersey or class II compression stockings (Venoflex; Thuasne, Levallois-Perret, France). The primary end point was the time to recovery of normal painless walking without requirement for analgesic drug. Secondary end points were time to return to sport activity, pain, analgesic consumption, and ankle edema (bimalleolar and midfoot circumferences). RESULTS: We randomized 126 patients and analyzed 117 patients (60 in the placebo group and 57 in the compression group). The median time to normal painless walking was not significantly decreased (P = .16). No significant differences were observed in pain, analgesic consumption, and bimalleloar and midfoot circumferences. No safety issue was reported. In the subgroup of patients with regular sport activity, the time to return to sport activity was shorter in patients treated with compression stockings (P = .02). CONCLUSIONS: Compression stockings failed to significantly modify the time to return to normal painless walking in ankle sprain. A beneficial effect was observed only in a subgroup of patients, as compression stockings significantly decreased the time to return to sport activity.

Parental presence during cardiopulmonary resuscitation of children: the experience, opinions and moral positions of emergency teams in France.

OBJECTIVE: To evaluate the experience, opinions and moral positions of French emergency physicians (EP) who had taken a paediatric university course on parental presence during child cardiopulmonary resuscitation (CPR), and to compare it with the responses of nurses on their teams. METHODS: A questionnaire was sent to 550 EPs who had taken the course during the previous 6 years; the EPs were also asked to give a copy of the questionnaire to nurses on their staff. Data were collected on experience of parental presence during child CPR, opinions on the practice, arguments for and against parental presence, and the moral positions of respondents regarding their perception of life and the sharing of medical/parental power in the decision-making process. RESULTS: 343 responses were analysed, 47% from EPs (29% response rate) and 53% from nurses. 52% of respondents had experienced parental presence during child CPR, but it had been the physician's wish on only 6% of these occasions. Only 17% of respondents favoured parental presence, with EPs (27%) being favourable more often than nurses (12%). The reasons against parental presence were psychological trauma for the parents, risk of interference with medical management, and care team stress. Respondents not in favour of parental presence expressed this view more for medical reasons than for parent-related reasons. The physicians not in favour of parental presence espoused a moral position predicated on medical power. CONCLUSIONS: A majority of EPs and nurses were reluctant to have parents present during child CPR. Their attitude involved medical paternalism.

Intervertebral foramen variation following dynamic L4-L5 interspinal device implantation: foramen size after interspinal device implantation.

STUDY DESIGN: This is a biomechanical study. OBJECTIVE: Measuring changes in foraminal size after L4-L5 interspinous devices implantation. SUMMARY OF BACKGROUND DATA: Low-back pain aetiologies include foraminal stenoses. A niche is developing for interspinal implants that are minimally invasive with few harmful side effects. At present, we do not have sufficient understanding about their impact on the foraminal opening. METHODS: Six fresh L2-S1 columns were prepared with preservation of the capsuloligamentary and discal structures. The L4-L5 foramen was particularly carefully prepared. A 2-dimensional photographic analysis measured the length and width of the foramen and the extraforaminal surface, both before and after the implantation of a supple interspinal device that preserves the supraspinal ligaments. Photographic calibration and the use of precise and identical photographic landmarks (pixels) permitted the calculation of the foraminal deformity. A Wilcoxon test was performed for statistical analysis with P<0.05 for significance. RESULTS: The average foraminal length was 15.7±2.8 mm and the average width was 9.4±1.2 mm. After the implantation of an interspinal device, it was 16.8±2.5 and 10.1±1.3 mm, respectively. The increase in the average foraminal opening was 7.45% and 7.63%, respectively (P=0.02). The average foraminal surface area was 150.4±35.8 mm and following intervention, this was 165.1±28.3 mm, that is an average gain of 14.65 mm (5.3-26.9) (P=0.03). CONCLUSIONS: Few interspinal devices have been the subject of studies on the foraminal opening after implantation. Among the initial strict indications on root compressions for which conventional surgery is too invasive, these implants could present a true therapeutic alternative. This supple implant significantly opened the L4-L5 foramen on the cadavers. Nevertheless, biomechanical data are lacking on its effects on the 3 planes following stress. Even if the impact on the foraminal opening is of interest, kinematic studies are needed to determine the exact effects before clinical implantation.

Validation of a performance assessment scale for simulated intraosseous access.

We propose an intraosseous (IO) procedure scale for evaluating the insertion process during simulation. A 12-item scale for assessing the performance of IO insertion into the proximal tibia reproduces all the steps of a manual procedure. The performance of 31 emergency physicians was evaluated with this scale on a mannequin simulating a decompensated shock in a 6-month-old infant.Our IO procedure scale was reliable, with a very high interobserver reproducibility. The application of this scale to procedures yielded higher scores for successful than for unsuccessful procedures (P < 10), a 93.5% success rate, and a mean placement time of 2 minutes 23 seconds. Although designed for a manual insertion of an IO needle during simulation, this scale may be also suitable for use in clinical settings.

Trophic factor and FR167653 supplementation during cold storage rescue chronic renal injury.

PURPOSE: The use of organs from deceased after cardiac death and extended criteria donors grew in the last decade. These organs are more sensitive to ischemia-reperfusion injury during transplantation and current preservation protocols do not protect them adequately. MATERIALS AND METHODS: In an autotransplanted, deceased after cardiac death donor pig kidney model we evaluated the benefits of supplementation with University of Wisconsin solution trophic factors and FR167653, an inhibitor of p38 mitogen-activated protein kinase. RESULTS: Supplemented solution improved renal recovery and limited ischemia-reperfusion injury, particularly when agents were used in conjunction. Long-term benefits were highlighted by decreased renal fibrosis, as determined by Picrosirius staining, and inflammation, as evaluated by renal cell infiltration. Mechanistic evaluation showed decreased expression of epithelial-to-mesenchymal transition markers, a process involved in renal fibrosis development. Tumor necrosis factor-α was markedly decreased in the treated experimental group. Apoptosis was also decreased, accompanied by decreased p38 mitogen-activated protein kinase phosphorylation. CONCLUSIONS: Supplementing the current gold standard kidney preservation protocol with trophic factors and p38 mitogen-activated protein kinase inhibitors markedly increased the quality of grafts in our pig deceased after cardiac death donor model. Hence, this represents a strategy of interest to improve transplantation outcomes.

Development of the right colon and the peritoneal surface during the human fetal period: human ontogeny of the right colon.

BACKGROUND: Development of the digestive tract during the human fetal period has been the subject of many studies, but there are no works that study the ontogeny of both the right colon and the peritoneum. METHODS: Based on the dissections of adult male cadavers and human fetuses, the aim of this anatomical study was to demonstrate the rules of the morpho-functional group, consisting of the right colon and its peritoneum surface, in human ontogeny. RESULTS: The morphology of the right colon results from a rotational motion, inducting the migration of the cecum in the right iliac fossa and formation of the hepatic flexure. This intestinal migration is based on the axis of rotation of the spreading area of the colon at the ventral side of the lower pole of the right kidney, which becomes visible after the 17th week. CONCLUSION: Our different observations plead in favor of the peritoneal fusion theory. A few variations of this fusion can explain all the disorders in the position of the cecum-appendix that are encountered in current surgery, as well as the possibility of internal hernias.

Normal ultrasound anatomy of the triangular fibrocartilage of the wrist: a study on cadavers and on healthy subjects.

PURPOSE: To report the normal sonographic anatomy of the triangular fibrocartilage (TFC) of the wrist in cadavers and volunteers. METHOD: Five hands from cadavers were examined sonographically before and after wrist dissection, during which the TFC was marked with surgical wires. Twenty volunteers without wrist limitation or pain, and without any history of wrist disease or inflammatory arthritis (mean age, 26 years (range,19-45 years) were also examined. RESULTS: Sonograms showed that the meniscus and the TFC were clearly separated. The meniscus appeared as a triangular structure that was homogeneous and slightly hyperechoic. Compared with the meniscus, the TFC appeared hypoechoic. The same patterns were observed for cadavers and volunteers. In 3 volunteers (15%), the TFC was not visualized. CONCLUSIONS: Using high-resolution ultrasound systems, the TFC can be separated from meniscus. However, visualization of the TFC remains limited due to its deep location and the presence of acoustic shadowing from bony structures.

Comparison of conventional and laparoscopic Hartmann's procedure reversal.

PURPOSE: This study compares open Hartmann's procedure reversal (OHPR) and laparoscopic Hartmann's procedure reversal (LHPR) in patients first treated for peritonitis (Henchey III or IV). METHODS: Fourteen patients who underwent LHPR during a 2-year period were compared with 20 patients who had previously undergone an open procedure at the same institution. RESULTS: Conversion rate was 14.28%. Operating time was shorter for the laparoscopic group [143 (90 to 240) vs. 180 (90 to 350) min, P<0.05]. Hospital length of stay was shorter for the laparoscopic group [9.5 (4 to 18) vs. 11 (6 to 39)]. Use of patient-controlled analgesia was not significantly shorter in the laparoscopic group [3 (0 to 4) vs. 3.5 (0 to 8)]. Morbidities observed in the LHPR group include a parietal abscess and an anastomotic stenosis without surgical treatment. The OHPR group had 6 complications: 1 anastomotic leak and 5 incisional hernias. CONCLUSIONS: LHPR with a conversion rate of 14.28% seems to be a method with shorter operating time and less morbidity compared with OHPR.

Influence of warm ischemia time on peripheral-type benzodiazepine receptor: a new aspect of the role of mitochondria.

The peripheral benzodiazepine receptor (PBR) is located mainly in the outer mitochondrial membrane and many functions are associated directly or indirectly with the PBR. We have studied the influence of different durations of warm ischemia (WI) on renal function, tissue damage and PBR expression in a Large Whitepig model. After a midline incision, the renal pedicle was clamped for 10 (WI10), 30 (WI30), 45 (WI45), 60 (WI60) or 90 min (WI90), and blood and renal tissue samples were collected between 1 day and 2 weeks after reperfusion for assessment of renal function. Metabolite excretion associated with renal ischemia reperfusion injury such as trimethylamine-N-oxide (TMAO) was quantified in blood by magnetic resonance spectroscopy. PBR mRNA and protein expression were determined in renal tissue. TMAO levels rose progressively and significantly with increasing duration of WI. PBR mRNA expression was upregulated between 3 h and 1 day after reperfusion in WI30, WI45 and WI60. Its upregulation was noted 3 days after reperfusion in WI90. At day 14, PBR transcript expression was not different from basal level in any group. PBR protein followed the same pattern. These findings suggest a new role for PBR which could be a major target in the regeneration process during ischemia reperfusion.